SI Joint Area Pain: Two Low Back Case Studies

What we're going to do is basically going to unmuddy the water. And I want you to imagine this is say you have a cup and there's something in the cup. And so we're going to shake the mud around. And so it's all cloudy and you can't really see what's going on. And so at this point in time, when we address the S1 nerve root and make it happy, we're going to let the mud settle. And once the mud settles, we're going to see what is actually in the cup still. If there's anything at all, there might be a dice in there. There might be a marble, you know, but we don't know what exactly is or if it's even there at all.

And so via this analogy, what I mean is, is do you have a hamstring strain? Maybe do you have pure form of syndrome? Maybe you're always allowed to have multiple diagnosis. And so I want you to know that let's settle the major thing first. And if there's anything there, it will reveal itself in the end. You're listening to the Restoring Human Movement podcast, where movement experts discuss the latest evidence-based practices to help you and your clients move with mastery. And now your host, Dr. Sebastian Gonzales. Hey guys, this is Sebastian, your host with the Restoring Human Movement podcast.

Thanks for joining the movement, movement. This is your first time. Welcome. You've missed a lot. This is, uh, we're well over 200 at this point in time. And this podcast is a 45 minute to an hour long format, ideally targeted at clinicians, but a lot of, uh, general population fitness, uh, PTs, and just patients who really, really care about what's going on in their body and how to get better tend to listen to this podcast. So I've created this podcast to help us all improve our patient outcome. And that includes, um, patients. If you want to listen in by all means, I don't, I don't think we try to make things too techie in most of the episodes.

It's more general conversation, uh, easy to understand. And cause a lot of times we, we end up having this whole other language in medical and it's not really fair to you guys to really, um, understand what's going on, what's expected of you if we're not clear with our, with our intentions. So, uh, we try to make communication a little bit simpler in this, but, uh, this one is going to be a solo episode where I am going to be talking about some of the really cool cases and patients that I've had over the last couple of weeks here. Uh, I, uh, I'm appreciative for all the patients I get to work with and that they trust me enough to, uh, work with them.

And, um, you know, they trust in my skillset that I'm not going to hurt them and make them worse and so on. So, um, I had a really, a couple of really great people, uh, recently that came in and I thought I would share. Um, I feel, I feel like, I feel like a lot of times, sometimes like we'll hear stories of like, you know, how, how patient care is really challenging on the, on the clinician or the therapist or whatever. And, you know, like you take your problems home with them, but there's other times where patients really builds you up and, um, you know, they, I, I personally enjoy my job. And so I enjoy my job.

I like working with the people. Um, and especially these types that make me, I consider myself almost like a sponge sometimes like you take people's problems on. Um, but also too, uh, they can, you know, they can squeeze out the sponge, I guess, in a good way. So, um, listen to this podcast and share it with some of your friends who are clinicians. If you feel like they'll benefit from it. The only way we get more listeners to the show is by you personally recommending the show. So recommend it right now, send it to a friend. Uh, I'll probably tell you at some point in the middle to suggest it again.

Um, cause we, we'll keep growing, we keep growing the podcast and it's been amazing. It's been amazing to learn from all the guests on the podcast and I want to invite you guys to, uh, learn along with me. So, uh, at this point in time, we're doing a podcast every once, every two weeks, just because I want you guys to go back and listen to the archives of all the amazing content there's been. Um, but it's also to, to give myself a little bit of a break too. I've been doing this for, I feels like 200 episodes have been, it's been over three years now. So give myself a little bit of break. Anyways, we're going to go into a little short story about myself because I like to share a little short story just so you guys understand who I am as your host.

And then we'll get right into the case studies today. So if you've been listening to the podcast, you'll know that, uh, I like boating. Uh, we got a new boat this year, not a new boat, but a used boat that we fixed up because we had the same boat for gosh, 20 years. Um, and it, it recently RIPed, uh, this last year. And so we got one and so it doesn't have a name currently. And so we're thinking about what's a good name for this boat, you know? And so we went on this trip and, uh, typically we have something on the, on the lake that we call it, we call it boat mentality. And so you're probably familiar with it.

If like you drive by someone skiing and you wave at them, they wave at you and it's mainly cause like they see you and you see them. It's like acknowledgement that you are not going to hit them and run over their skier. And so basically we tend to wave at everybody, you know, whether they're going slow, fast, whatever, we try to get waves. And so we've been driving along, just waving at people. They don't wave back until we hog the horn. They wait, they finally wave back. And, uh, we say, yeah, collecting waves because we're collecting waves. And so we're thinking that the name of the boat could be not set in stone, but could be collecting waves.

Anyway, let's get on to the show. So recently there was a, uh, a gentleman that came in. He was younger gentleman. And, uh, by the way, uh, he was, he was under 25 and I worked with him a couple of times. So it might be too early to really tell where his case is going to go, but it looks very favorable at this point. Um, but I say under 25 because I don't really see, I don't really see a lot of young people who actually invest in their, in their body and he's paying for it himself. Uh, he wants to get better. He recognizes that the pain that he's in is affecting his quality of life and he wants to get back to what he wants to do and, you know, be active, go to the gym.

Um, he, he felt like it was basically stealing, you know, some of his life away from him. And he divulged some of this in the intake form. We have a very detailed intake form, which, you know, covers what are your goals? You know, what do you believe about your injury? What do you think is creating your problem? Um, and things of that nature. Um, so we really like to go into goal setting and want them to dig deep. Um, cause if they dig deep, then they're going to get to their goals. I believe anyways. So, uh, this, this gentleman came in and, uh, he had lower back pain kind of around the SI joint, also around the piriformis buttocks region, um, into the thigh a little bit in, into the outer aspect of the ankle, not really too much into the foot.

And so this, I know we can all, the clinicians will say, well, maybe this is a sciatica. You know, I w I would probably agree with you. And I, again, if, if there are, uh, patients listening, many of you will get confused maybe about what it is. Cause, uh, I know he was, and I know a lot of people who come in with these types of things are, and I think that's why they're in the situation that they're in is that they tend to, they, they take, they take, uh, what we've done, I think of a really poor job of doing in medical over the years is consolidating things or partitioning things rather partitioning things into quote unquote syndromes.

Uh, you might've heard me and Cody DMACC talk about the syndrome syndrome, uh, way back when, I think it was episode maybe like 104 or something like that. You can always scroll back again. This is the opportunity. So while we're going once every two weeks, you can go back and listen to the other ones. And so we started to like classify the, a lot of things as syndromes. And so, uh, he came in and he's like, well, I think I might have SI syndrome and then maybe some pure form of syndrome. And I think I've maybe like a, uh, an ankle like muscle it's like torn and you know, maybe like a quad strain, you know, or, or like a, uh, or a thigh muscle strain, like a hamstring strain.

And so when we first talked, I, I, I've been trying to do a better job at this recently of helping people understand that I know where they're coming from and I understand I'm hearing them. I totally hear them, but I want to make this simpler, uh, because I don't think it has to be this complicated and making it more complicated is not a good thing. Let's just make it super simple. And we start to, um, figure out what the main center cause is. And I know a lot of people have heard, well, what's the root of the problem? You know, we've got to find the root of the problem. What is it? Well, um, that is important, but also I try to take the other route and say, I recognize you have all these other things.

Okay. Just know they're probably part of the same thing because I think when we heard stuff, when we hear stuff enough, you know, like the root cause, it's easy to just glaze over what that really means. Uh, I know when I go to the grocery store and, uh, they say, Oh, how did you find anything? Okay. I know they don't, they're not asking cause they care. It's just kind of like a robotic thing. And so I think sometimes when we hear something too much, like the root cause, then we don't really take it, um, seriously. And so I told him that, look, I know you have all these things in it. And, uh, I know you have pain in these different areas, but I want you to understand that, that I think we've done a bad job in medical of creating all these compartments for you to put symptoms in.

Okay. And so you might feel like you have SI, SI joint syndrome. You might feel like you have piriformis syndrome. You might feel like you have a hamstring strain and a, uh, pronious longest strain, but I want you to know that I'm going to be ruling a lot of things in and out today. And there's a high probability that all of the stuff that you're talking about is from the exact same thing. And here's the cool thing is all of it. Most of it will settle itself if we just address that center center thing. And so we're going to figure out what that center thing is today. And, um, I think you're going to find that there's a great reduction of your pain today.

And we just have to get you to do some of those things at home to, uh, keep, keep the progress going forward. And, um, I'll usually use the analogy of, of a glass with mud. And I might've mentioned this in the podcast before, but I, I've certainly mentioned it to more and more patients because I think it's a helpful analogy is, uh, cause a lot of times they'll, they'll, we, we say we're looking at the SI joint or the back or the sciatic nerve or whatever we decide is the thing on that day. In this case with this gentleman, we're looking at mainly a nerve root, uh, S1 nerve root in particular. And I said, look, if we look at that S1 nerve root and we get it to become happy, what we're going to do is basically going to unmuddy the water.

And I want you to imagine this is say you have a cup and there's something in the cup. And so we're going to shake the mud around. And so it's all cloudy and you can't really see what's going on. And so at this point in time, when we address the S1 nerve root and make it happy, we're going to let the mud settle. And once the mud settles, we're going to see what is actually in the cup still. If there's anything at all, there might be a dice in there. There might be a marble, you know, but we don't know what exactly is or if it's even there at all. And so via this analogy, what I mean is, is do you have a hamstring strain?

Maybe do you have pure form of syndrome? Maybe you're always allowed to have multiple diagnosis. And so I want you to know that let's settle the major thing first. And if there's anything there, it will reveal itself in the end. So, or even my next week. And so he did that. And so I went through the assessment with them. He was, he was able to reduce his symptoms by half within under five minutes of an intervention. In this case, we did a neurodynamic shack lock sideline opener. It worked very well. It centralized his symptoms. He wasn't fully out of pain. He still had a good reduction, but it looked telling enough to continue down that direction.

I didn't adjust him. I didn't, I didn't have to do any soft tissue work on him at that point in time. And I think if I recall, I gave him a corrective exercise to do. That corrective exercise, when I look back in my notes, is we gave him a banded bridge to do. The banded bridge is something I learned from Ben Ramos and it is, it's just horribly effective, but also painful, like as an effortful, like it's, it's challenging. And so we use that banded bridge kind of as an attractor state type of approach by really, as we in DMACC would say, is smoking the glutes. We just smoke them. Right. And so what I tell them usually in this, and then what I told them in this case was, look, if you don't remember anything else today, I want you to do the sideline opener.

That's it. Okay. Once you do it, um, quite a bit of times throughout the day, I want you to break it up. I don't want you to do it all at one time. And I think you're going to find that every time you feel you, every time you're there, all you, nearly all your pain is going to go away. Because in the exam at that point in time, he was able to be in that position and have absolutely zero pain whatsoever. Then we'd retest and retesting would, would bring his pain back a little bit, but again, it's, it's 50% better. So good to good plan of attack. You can't expect a complete reduction with everybody on the same day.

It's just, it ain't going to happen. So based upon what we know, um, I could have taken a couple routes with this. We could have done since it's, since a sideline opener or sideline opener helped him. Um, let's just say this was, uh, was it, this was his right leg. Let's just say, uh, lateral flexion to the right would create, uh, intervertebral, intervertebral framing or hole closure on the right side, affecting the nerve root. Uh, if this wasn't disc related, if it's just, um, nerve root, uh, IVF mechanics related. So I could have done a side plank on the opposite side, same type of attractor state model.

Um, I would have smoked the left side of his, of his core, hopefully to build a breaking system against him leaning too much to the right, or we can address the glutes. Um, it's a coin flip to me. Sometimes, um, I can do some examination to see in that case. I didn't know. Sometimes you do the exam to see, uh, say have him lean backwards. Uh, if I recall actually bending backwards, I should, I should go through that. I'll go through his case, uh, how he presented. Um, he didn't, he had pain walking. Um, he, uh, um, it was pain with bending over, putting on shoes, uh, relieved by sitting and laying on his belly.

So that's the relief by sitting was the interesting thing, uh, to me in his case. And for range of motion testing, um, it was painful with flexion, bending forward with knees locked, but unlocking that knee took all of his pain away. Um, bending backwards was also painful too. Uh, Kemp's was slightly painful as well. Um, as we're looking at the possible IVF closure and, or not closure as in it's gone forever, but just like, uh, closing mechanics are what's bothering it. And, uh, that's why I chose the opener first. We also did try some, some prone press-ups too. That just didn't have a good enough effect on him.

And the silent openers look better. So, um, but we could do a side plank as in smoke the sidewall on the opposite side to build a, um, uh, build a, a breaking system towards right lateral flexion in this individual, or we could just work on the glutes. And the glutes, sometimes I'll check with these tests. Like if he has pain with, um, extension, standing extension, I'll just have him squeeze his butt cheeks together really hard, like he's kind of break a quarter between his butt cheeks and have him do it. And a lot of times this will shift. My theory is it shifts the hinge point away from the spine and into the hips again.

And so it stops the relative IVF closure, um, obviously on both sides in this case. And so by doing a banded bridge to the point where he has nothing left in the tank, uh, it will, in theory, produce a, a better resting tone, a protective tone. Um, is there a, uh, uh, a subconscious, um, type of movement exposure aspect to this? I have no idea. I'm not going to go down that route because it's a whole nother rabbit hole. But for the most part, we did banded bridges. He came back the second day. Actually, we called him a couple of days later. He's like, dude, I feel so much better. He was like, he was like, uh, a static about it.

Like he was very, very excited. Uh, in that point, actually we had, we said, Hey, you want to do a review? You know, let's, let's review it. Let's review all that. Everything you said, just, just review it. And so, uh, this, the next day he came back, he came back a week later and, um, he was much, much better. Um, he didn't have any pain into the buttocks or the SI donor. He still did have some prickly type of feeling into the lateral aspect of the ankle, which, um, that was the one major thing we addressed first on that day, um, because you get to address peripheral symptoms first and he was feeling much better in the other spots.

And, um, he did have some trouble with the banded bridges at home. So he had stopped it. And so, um, I wanted to see what he was doing. So usually on the second day, I'll, I'll ask him just, they walk in, I say, lay on the ground or wherever you need to go and say, show me what you were doing. Cause I want to see if they did it well. If they had success, they probably did it well. Cause we had already kind of tested it in, uh, the, in, in the session before, but they, if they were doing it poorly or they were having some type of thing that I could see, well, maybe why it was not going well, then I need to address that.

Cause there's no point going forward, giving them other things to do and extra things to do. If we found that last time we, there was a favorable response. Things worked last time, but why isn't it working now? So, um, he, he did a banded bridge and there was a lot of low back extension. And so a banded bridge or bridging pattern is, is a lot of times a lot of, um, it will dump in the low back as we say, um, when the hips terminate range or the lumbar spine can extend a little early. And so in somebody who has, um, in theory with this person, uh, an issue with closing in the IVFs, compressing the S1 nerve root, um, this won't feel good on him on them.

So we can take a couple of different routes. And so we can have them do like a, like a DNS, like poke the side of the belly, like assess intra-adominal pressure type of cueing. Uh, you can also take, uh, uh, a weight, just a kettlebell or something, put it on their belly and say, don't let the kettlebell smash you. It can be like 25 pounds, something like that. Um, usually that works pretty well because it stiffens the, the, the torso up a little bit while you can still move the hip, uh, ball and sockets. Um, in this case, I had him actually assess his own, uh, rib boob in this case. So I had him place his hands on his belly while he's laying on his back.

And I put his, we put his thumbs right over his lower rib cage. And I said, I want you to make a little diamond right there and just feel your belly. I want you to feel the ribs right there. And I want you to stay on the ground and start right there. And I want you to just flatten your back against the ground. Do you have any pain there? No, I don't. Great. Do you feel how your rib cages is flush with your belly? Cool. Can you feel that there's some stiffness under that whole area? Yes, I do. Great. Keep that. And I want you to break the band and then raise your, uh, raise your belt buckle to the ceiling.

And so he starts to go and, and he, I can see he was selfish. He was, he was, um, figuring it out. And so he's self-correcting. And so I wanted the tactile sense of feeling the ribs, Ray, elevate as being the thing. Um, I personally like using the kettlebell in, in most cases with people because it provides a nice external cue. Don't let the kettlebell smash you. Um, but in this case, I think using the affirm feedback, the sensory receptors of the, of the hands is not a bad idea. And someone who's had a little bit of an issue with this, he actually did have, um, issues a little bit through the first round.

And so I scrapped that back and, uh, we went into, I got a Swiss ball and I had him just lay forward over the Swiss ball and then literally hump the Swiss ball. And so what this was doing is giving him some nice, um, feedback for, uh, posterior tilting the pelvis while still keep, still keeping some stiffness of the abdominal area. And so he was able to do this. It looked much better. We gave him about 10 reps and we drove, we stuck them back, right back in, in the banded bridge. And so we did much better after that. Um, we also did some, some belly, um, or anterior wall stuff too, or anti extension of the torso.

Uh, we did it via a hard style plank. I do love the hard style plank. It's a really easy one to teach. Um, Allie, which you've heard on the show before, she called it a turtle plank because you're making like a turtle shell. Just allow them to round their back a little bit since rounding in this case, um, it was more extension was driving his problems. Rounding didn't bother him, especially when prone. And so he really struggled with getting the, uh, uh, his low back to stop, um, arching or, um, arching, I guess, as most patients would say, uh, I guess in medical, we'd say increased lordosis. And so he was dumping there a lot.

And so we had to keep scaling them back a little bit. And, um, if you worked with people with corrective exercises, um, again, it's not the exercise. That's the magic. It's how you cue it. And so you need to figure out what you want to get out of the exercise. In this case, I wanted a posterior tilt. I wanted the belly engaged and I wanted, I wanted, uh, breathing throughout the exercise. Okay. And so I, we had him hump the floor and I said, don't try to get up, just hump the floor so hard that you by chance get up. Or when you like, a lot of times I'll lay on the ground with the patient and, um, I'll feel, I'll feel what they're probably feeling if they do it well.

And so I laid on the ground, I humped the floor. And then I realized that I just went to my knees, like the knee, the thighs magically elevated, the belly magically came off the ground and the weight went into the knees. The floor contact went into the knees. So I said, hump the ground so hard that you get into your knees. And so that's what he did. He did pretty well. It was very hard for him to do, but he felt amazing afterwards. And, um, he's, he's working so hard during which, um, just shaking great tension as, uh, Dr. D-Mac talked about, um, a couple episodes back, um, being able to regulate tension, uh, through these challenging positions for him, I think is going to be key.

Um, and it helps the body kind of figure out, uh, how to, how to use that tension appropriately. And so using that tension on the anterior wall, I think, especially in the heart, in the heart style plank helps his lumbar spine, relax, helps the muscles on the backside via reciprocal inhibition, just relax. And so we also stopped dumping lumbar extension in the area, stopped pissing off the S1 nerve root. And so hopefully the reason why I took this route with him was because, uh, I feel like doing the corrective exercise, number one, made him feel better. Number one, or sorry, number two, he was able to move better.

He was impressed. He had buy-in and I think it's a better long-term approach than just doing, um, uh, a pat, a passive care or a passive stretch. Like, like we did with the opener. Granted the opener made her feel good. I think it's a necessary first aid. And I tell patients all the time that, that, cause they, sometimes I ask what makes you any different than any other place that I've seen and it hasn't worked. And I said, well, you know, um, I think we pick a first aid. Not everybody picks a first aid. Sometimes they just jump into the next step, such as the correctives. There's nothing wrong with the correctives that you did.

Nothing wrong with your planks. Um, nothing wrong with your bridges, nothing wrong with, they told you do squats, but I think you just needed a, a, a step before that. And so the first aid, uh, we know that pain corrupts movement. It does. And so it's very hard to get those correctives and the strength strategies to stick if there's still a significant amount of pain. And so we need to, to modify that pain and then start to load that pattern. The corrective exercise in this case is to reme, to be like a remedial loading for that pattern. I wanted to load his hip hinge. Um, but I couldn't stand him up and do a deadlift because he clearly couldn't even do a bridge.

And so we stuck him with the bridge, but, uh, usually with people with sciatica, because, uh, or I take them to a split squat or, or a squat. Usually if it's not disc driven, if it's just neural tension driven or radiculopathy, uh, mainly because the knee bend is there. Usually they won't lock the knee, um, and they won't get into like a possible slumps position as they would maybe with a deadlift. And so I just split squat him to a block kind of in a Mike, uh, Mike Boyle style. Um, we did a split squat in that fashion. I had him do it with, with a load into a kettlebell into his opposite hand that the leg that was forward.

Why? Because it increases the leverage or the moment arm rather on the front side hip. Cause I want to bias this again, towards his hip quite a bit. Granted it's a quad dominant movement. We know that squatting the quad dominant movement, but I wanted to bias it towards that left hip to challenge his frontal plane. Essentially, if we think about it, I mean, I didn't give him any side planking to do. I could have, I could have gave him a farmer's carrier suitcase carrier to challenge a frontal plane, but I could do it with a, with a, with a contralateral hold split squat as well. And so that's why I chose that.

Um, it was very hard for him. He did an excellent job, um, struggled through the right areas to struggle through. He didn't use his momentum to get up. Um, he just struggled through and push the floor. Uh, when at all possible, you want to cue from a distal point, such as a hand or a foot and have them push the floor or crush the object. Um, it's the easiest thing to do to really get everything linked up into the chain. So, um, again, great case, great person to work with. Um, very motivated. It's exactly who I like to work with, um, because they're excited. I'm excited to share their successes with them.

Um, and they're on board, they do their homework, you know? And so there's never like that whole, um, you know, lecturing them about what they should be doing because they really want to get better. And so, um, within the second day, I cleared him to do arm and arm shoulder stuff at the gym, um, split squatting, uh, anterior load squatting and, um, carries. So quite a bit. And so, uh, you might wonder why, why are you giving him so much, um, leeway into loading? Well, cause those patterns didn't hurt him. Okay. We have to be a little bit more conscious. I think what the patterns that actually bother the patient versus just, uh, stripping everything away.

Okay. Deloading the person completely. I don't think it's going to do them any favors. And he was actually pretty honest about, like he said, he's thinking he got worse when he, uh, uh, once he stopped, uh, going to the gym. So, uh, I prefer to, to, I don't want to un, un, unravel their entire loading process because I think all these movements work together. Um, but we have to be a little bit more strategic when we're loading the movement strategy that is bothering them. Uh, and then we just shift load around and, uh, then we'll eventually bring it back. You don't just eliminate it completely forever.

Um, I guess I should mention too, he, since he did have some ankle, uh, I think ridiculous symptoms in the beginning, uh, I, I think there's many ways to skin this cat. And I thought, well, maybe we were on the ground at the time. And so I could have just had him lay in a little opener thing too, but, um, he's already been doing it. Um, I think he, he'd done it for about a week. Uh, it did very well for what it was, but you know, sometimes just adding flexion is not a bad thing. And I would, I wanted to progress down the route of having breathing, uh, being accomplished too. And so I had him do a happy baby and he grabbed his ankles from the lateral aspect or sorry, his, his soles from the lateral aspect.

And I told him to bring his knees to his shoulders and actually look through his, his, uh, thighs and just breathe into his thighs, breathe into the ground. Let your back be flat on the ground as much as it can. And just stay there for about a minute. He was just blown away. And he's like, this feels so good. My ankle doesn't hurt at all. I have zero pain whatsoever in this position. Um, so we use that as, as a way to, to regroup every time. If he had a flare up, he didn't really have a, uh, too many flare ups. He had a couple when we went back to that band and bridge, but for the most part, he did a very good job, um, of, of controlling his movements, uh, and paying attention to what his body's, uh, telling him throughout the exercises.

So, um, but that happy baby, I haven't, I haven't used that much in the past, but, uh, I'll probably use it more. And I know that some of you will probably think, why, why'd you give him flexion? You know? Well, I mean, I, so I could have given him something like a, uh, like a passive flexion or a stretch, like a knee to chest or something like that. But I kind of think when at all possible, we make this thing a little bit more active. Uh, we build a, we put another support system in there so we can actually mitigate more risk. Um, because taking a, taking the spine or a joint through passive range of motion over and over again, I think it's a little bit more risky than actually allowing the body to control that movement and have some support.

In this case, intra-abdominal pressure was the supportive system, um, because it was had that water balloon as he was bending forward. So it supports the spine from the anterior aspect. So very supportive. Now, really quick break from the show. I want to propose a educational series to you guys, for you clinicians out there. This is not intended for patients. Uh, I recorded a webinar series, um, a little while back. I recorded it. It's over 15 hours easily when you put all six parts together, but I broke them up into two, three hour bits. We cover what I call the five-step patient care, uh, system.

And I've developed this because I've been training interns and this is a good way to organize thoughts for them and also easy way for me to teach too. And so step one is history taking, working diagnosis, physical examination, dynamic testing, and good exam flows. Just really good, solid exam flows, knowing when to use them for hips and shoulders and backs and cervical and so on. Also, we do cover first days, how to get people out of pain without having to use medications and really without even having to put our hands too much on them either. That's very empowering shit for people to be able to do stuff on their own.

We also cover corrective exercises, which is number three and when to use them, how to use them, which ones to use, how to cue, how to cue them, how to coach them. Then we cover loading. DMAC, Dr. DMAC also covers a little bit into the other products we have on the page too. Um, that one is, if you want to go a little bit more into depth on number four, which is loading, uh, Dr. DMAC covers that again in 12 hours of the low back one or sorry, no, it's two hours, two hours of the low back one and another two hours of upper quarter and cervical spine. So as you can see, I could not fit it completely within the five step series because it takes more detail than that.

So he covers a little bit more thoroughly in there, but I do make introductions into it and I do do some of my coaching and cueing style too, which is a little bit different than his. However, uh, I want you guys to go through this and really take the heart. The, what I'm going to say is, uh, and taking the light that is intended. If you don't get this shame on you, shame on you because it is one of the most educational, useful, cheapest, um, series that you can possibly get to improve your clinical knowledge. Um, uh, again, I don't say that lightly, but I, I feel like a dick when I say it is, um, if you don't get it, I don't, I don't know what you're spending your money on.

I don't know why you're going to all these other workshops that show only little tiny parts of things. And so this is an organizational series. I know a lot of you already know how to do tissue work. You already know how to do some stretching techniques. You already know some exercise techniques. Why do more? You might as well just figure out where you're missing things and learn that one, learn how to plug in those things you already know. Many of you are very, very good at tissue work already, and you don't need to go to more. I know that I spend a lot of time doing a lot of tissue work. I don't need to learn a lot more.

I probably need a little bit more, but not a lot more. I need to figure out where my, where my competencies are lacking. And for many years, my competency was lacking in corrective exercise, Q and loading strategies. And so after plugging those things in, man, fricking game changer, fricking game changer. Anyways, we cover hip, shoulder, low back, cervical spine, and referred symptoms. I'm going to share with you a review that we have on the low back one, uh, taken by one of the people who went through the course as I taught it live. I highly recommend this guide to any chiropractor and physical therapist looking to up their game in treatment of the low back.

The guide is a great supplement to anyone who likes crisp book protocols by Don Murphy. If you read those books and agree with the patient's needs to have better control of their own health, then you will love this. Sebastian Gonzales gives you a step-by-step guideline of what to look for in examples of exercises for treatments that will be useful the next day, not just theories and concepts. Great. Well written. I like that. So please go through there again. Take my comments in the light that it was intended. I want everyone to improve. I want our profession to improve. I continue to learn people who have been around longer than me as well.

Um, and there's no need for everyone to struggle and try to reinvent the wheel. I know our, we get frustrated when our patients try to struggle through some of the easy stuff that you could teach them. Um, don't make the same mistake they do. Don't let them go around on YouTube videos, looking for solutions when you have an easy solution for them. So p2sportscare.com slash products. You won't be disappointed. We'll see you on the other side. Back to the show. So, uh, that was that case. Um, God, that was, I spent a lot of time on that one. The second case, uh, I'll cover that here and I'm going to stay on the same thread of being a low back, uh, SI joint area, just because this is going to be, uh, I guess I can always jump around, but there's no point since I had someone else who was a great, uh, demonstration of, uh, of how things work as well in this area.

So this low back case, uh, he was also somebody who, uh, it was in the SI joint area. He was around the age of 30. He's had it for a couple months as it being acute. Um, but it was, he's had problems on and off over the years. He said for about seven, eight years or so. And so, um, he was extremely motivated to, um, we've only seen him one time, so I can't speak for what will happen the next time, but I can tell you in theory what I'm probably going to do with him. Um, it was basically just localized, uh, low back into the SI joint area. Um, he's had some, some peripheralization, uh, in the past, it's worse in the morning.

Um, it was relieved by putting his knees to his chest. Actually, you know, it's surprising how many times patients have told me that stretching in the, in the, in the movement, I think is probably going to make them worse. Actually doesn't. It just ends up like they say, it makes them feel better. You know, um, I think something that we should not completely ignore, um, is, is having them do, uh, just telling, telling them or asking them what makes them feel better. And if they say, look, I put my arm over my head, it makes me feel better every time. That's important, you know? And, um, I wish I could say that all the things that we kind of learned as our biases have kind of formed that, you know, like stretching is not good.

Static stretching has no relevance or rub dirt on it has no relevance, walking it off. I mean, all these things, people do them because it somehow makes them feel good. So is it bad to just take it away? You could just have them do it, you know? Um, so a lot of times them telling you what makes them feel better is a good insight into, uh, learning about what to give them. And I remember this one guy way back in the day that he had, he just had some ripping sciatica and, uh, uh, press-ups helped him. And, but you know, what made him feel really good was just sitting cross-legged on the ground. So just an aspect of flexion, like an active flexion, uh, knees bent.

So it decreased neural tension. It took his pain away every time. Um, so at some point I stopped fighting that. I gave him press-ups for a couple, a couple of weeks. Um, at some point I, I, I stopped fighting that though. I said, do that more. Sit, I want you to sit down there. I want you to eat down there, you know? And so, um, very helpful, uh, and it did go away, uh, longer case than I wanted, wanted to have, but he had intermittent stuff for about, I'd say about eight weeks or so. Maybe it was a little bit longer than that, but it was, um, we, we got through the bulk of stuff really, really quickly.

But anyways, back to this case. Um, so this guy, he had, um, uh, he ended up hurting himself, um, playing, what was he doing? He's play, he's doing jujitsu, I think. Um, but it's aggravated with twisting, standing, walking, standing, driving, lifting 20 pounds. Um, you know, better with knees to chest. Most people say it's better with, you know, stretching. Um, he said forward bending was pretty good. Bending backwards was actually kind of painful to him. Um, right in the area of the SI joint again, um, is it the SI joint? I, I, I don't think so. Probably not. Um, I, I think you probably heard me on another podcast that the SI joint is really, ever the problem.

I know people think it is, but if I was looking for unicorns, I would look for an SI joint strain all the time. You know, like it's rarely ever there. Piriformis is rarely ever there. Yeah. Can they have pain there? Yes. Like, excuse me, uh, man burping. Um, they're rarely over there. Like if I had to guess and you're probably going to hear me over and over again, if I had to guess, uh, SI joint and piriformis actually true syndromes would encompass. Less than 10% of any of the cases that you're going to see it, uh, at least if you see a population like mine, you know, your population might be different.

I might be completely wrong. You might be someone, you might see someone who absolutely just, uh, you know, their job is, uh, you know, uh, tap dancing, you know, that a lot of external rotation isolated into that. I don't know, you know, but, uh, you'll, you, most people will rarely ever see it. Although the hub pain in the area, this guy had full flexion, no pain whatsoever. Um, he didn't have any positive neural tension signs either. I was very, very surprised. No SLR, no slumps test. Um, the extension pattern staining extension globally was painful. It reproduced pain. So did some twisting.

Um, so whatever I usually start on these people again is I, I go for the percentages and if you've, um, gone through the workshops that I put on, by the way, I do suggest the workshops. They are virtual and they're available right now. I'm sure I probably put up, um, a break in the podcast for you guys to find it, but you really should. Um, I think the thought process of it is, is, um, you guys will really enjoy it. And so usually with someone at a 30 years old and it's, um, far to guess, you know, like he, he had, he had all the, all the stuff that was like sitting, driving, lifting, you know, it was like twisting.

Okay. This might, might be a disc. He didn't really have back pain per se. He has SI joint area. Um, and so I, I don't like to miss out on a high percentage win. And so I just make it part of the assessment. You know, I just, I tell him it's a long test. I want you to do a bunch of press ups for me. And if we do a bunch, you know, I usually have them do 20 or so. I even load them. You know, I lean on them. I load them, um, load the spine into extension just to make sure that is actually truly, um, going to work or not work. Also too, I'll go, I'll have them go prone. And I'll lift their, uh, ankles or their legs up, uh, basically extending them from the backside from, I guess that's the, what's the opposite of caudal now?

No, that's probably caudal. It's not cephalad. It's caudal, um, from the legs. I'll, I'll lift them up to see if they hurt a lot of times, surprisingly with, with, uh, people who are more disky, that doesn't hurt people who are a little bit more nerve rooty. Yeah. That tends to hurt. And I'll put them into a prone prop position. So I'm sit there a little bit. And so a lot of times people with a disc and nerve root, a lot of times when their back is active, it's really helping that it'll hurt either way. And so I don't like to take the chance. I just, worst case I make, if I make them worse than I can, I know I have the information to make them better.

So I just have him do some press-ups in that. Um, and it didn't make him better. And so we went the similar route that we did on the, uh, other person that we saw, uh, or that we did the case presentation on. And as we did a shot clock sideline opener and worked pretty well, but not perfect. You know, it was, it was funny that with this guy, um, he was a good example of, you don't always need a first aid. And so it helped a little bit, but we really had to take him out into the weight room to give him more of a step to, um, actually I said, I guess that'd be step three, a corrective exercise or supportive approach to get really the benefit that, that he wanted the, the results that I like to see.

And I know that, uh, I said this a lot of times before is that you should be able to predict your outcome. Like I want to see that people are impressed on day one. I know a lot of strategies, especially within certain areas of the body that really will make them impressed on day one. I want them to come back. Like the number one thing is get them to come back. If they come back, I can help them. If they don't come back, uh, even if I did help them, I don't think it's a good long term. It's not gonna be a longterm fix. It's not going to help them longterm because it was, I gave them a temporary strategy, a temporary first aid or temporary corrective exercise.

And mainly as a, it was a, it was a, it was an approach just for a couple of weeks. It wasn't intended to be a longterm thing. Um, I like to get them into some more strength conditioning. They don't have to lift a lot of weight, just something just to build some supports to get close chained on things. And, um, he was somebody who did not really respond well to a first aid. So I took him out in the weight room and we did some fun things. And so, uh, what do we do? I'll look back in my notes here. So we did similar to what we did in the last person. And, um, I think you're all probably starting to see, and I know I've said it before.

You don't need a bunch of fancy corrective exercise. You just need a couple. Um, and I'd say by a couple, I probably mean 20, 20 to 25 maybe, um, because the body's pretty big and bias them based upon what you're trying to get out of, out of the exercise and out of, out of the person to get a change on that same day. And so we did a glute banded bridge and we did the hard style plank again, because since, um, the opener helped them a little bit again, I could have gone sidewall again. Um, but you know, I, I like to make it as easy as possible. And, um, we went the route of this because we tried a, we tried almost like a stork test where they bend backwards and with two feet on the ground and it feels bad in this case.

And then you have them deload one foot a little bit to engage the frontal plane on both sides. It doesn't matter. And we see if that has a change and it doesn't. And then usually, uh, I mean, it can, but it didn't in this case. And usually after that, I'll have them squeeze the butt cheeks together. Like they're breaking a quarter, just as I did earlier with the other person. And that makes them feel better or I'll slap their belly and they'll arch back. And that makes them feel better. Meaning I'm going to bias this exercise towards the glutes or the belly wall as an anti-extension type of thing for the lumbar spine.

Could we do frontal plane? Yeah, but that didn't make a change with them with testing. And as I said before, um, make sure your exercises have a purpose and know why you're selecting them. Um, because they're a medication too. They're, they're, they're medication and you need to pick the right dosage as well. And so we did a band and glute bridge and a heart style plank in the same fashion as the attractor state, uh, keto, keto van rice again, type of approach and just smoked the glutes, smoked his abs. He got up and he's like, Holy shit, bent backwards, no pain whatsoever. He was so excited, so excited.

And so we called him the following day, still felt great, still felt great. And so, uh, I imagine his case is going to go very, very well. Um, again, you should be able to predict your outcome. Uh, when someone walks in like this, I know we're going to have a good experience for the most part. Obviously there could be dropout. There could be the, uh, I could pick wrong. Um, and I could have picked wrong on these people, but when it comes down to it, um, as long as the person is willing to come back to allow us to fail, to allow me to fail a couple of times, I'm pretty sure I'm going to get it and I'm going to help them get to their remedy and I'm going to give them the appropriate homework to do.

And then they're going to quote unquote fix themselves. Um, but I picked wrong a lot in the past and I've sent people home with, you know, the wrong first aid and they have not gotten better or they've, they've gotten worse. Um, and I think I've told the story back in the past is there was one gentleman that came in that he, he had, uh, sorry, he had a low back pain. And so, um, I gave him press ups to do and, uh, he came back three days later and I said, did you do him? He said, nope. And I said, do you feel better? He said, nope. And I said, uh, and he said, what do you do? What about, what should I do?

I said, same thing. I'm not going to change my mind just because you didn't do it. It doesn't make me change my mind. Do it. And so he did it and then he came back and he's like, holy shit, it's down my leg. And I said, oh, that's, that's okay. Good. Now we know what to do. And so I, we basically did the direct opposite and then he got better really quickly. And he was kind of confused about why is that good? You know? And it's like, well, it's, it's not perfect, but it's, it's, it's more information for me and it helps me guide you even better. But if you don't do it, then I don't know. And the second thing is if you don't come back, then I can't, I can't use that information to help you out.

And so, um, obviously in this podcast, I didn't cover, you know, soft tissue work and adjusting and icing and heating and stem and percussion instruments and so on, but all that stuff does have a place in first aid. I believe that each person only really needs one first aid. If you're in a, if you're in a rare circumstance, maybe give them a couple, but give them less things to do. Make it simple. Try to cover a lot of basis, um, cover a lot of ground with a simple first aid, de muddy the water. And then we start to load up that pattern and eventually get them into a closed chain, uh, exercise, you know?

Um, now if you do the other types of first aids, by all means, just be able to predict your outcome, right? Like I, I tend to not use them quite as much because the stuff that the way I'm using these strategies, I can predict the outcome pretty well, especially with many types of shoulder, neck, uh, headache, low back, hip, thigh, um, knee. And then we get a little bit more obscure into the other areas and have to, to go a little bit more off the wall, but be able to predict your outcome. That is, that is the very important thing you need to be able to do. Um, mainly because the patient's going to look at you for, for, uh, they want to see that you're confident.

Okay. You should be confident in your care and their outcome, um, because you believe in it, not because you're trying to sell them. I always tell people and the interns that when they answer the phone here, that, that if they go, if this person goes somewhere else and has uneventful care, then it was a huge, we did them a disservice by not convincing them on the phone to come in and at least give us a shot. Cause I know we can make a big change in a little amount of time. And so we're very confident in that. And, and yeah, business is about sales. Yeah, I get it. If you see people longer, you make more money.

Yeah, I get it. Um, but I know that, um, people, uh, some people have asked me like, well, what's your, what's your maintenance care? You know, um, I like them to come back once every four to six weeks to do some, uh, change of exercise programming, not more correctives, but more loading, more strength conditioning, make them stronger. Now, should they be with a strength coach or a trainer at that point? Sure. They could be, it doesn't matter to me. My recommendation don't change. You do it here, you do it there, you do it on your own. I don't care, but the, uh, don't not do it. And a lot of people that we find is they, when they come in and they've had such a problem such as these two people, a lot of times they trust us to suggest those loading strategies because there's a big gap between corrective and loading.

Um, and a lot of clinicians, um, are very good at suggesting corrective exercise. But, uh, as you heard me talking with Cody Dimak about it is that, um, we don't learn strength and conditioning cueing specific to pathology at school. We don't learn that most of our internships. And if you were to shadow a strength and conditioning coach, they're working with healthy populations. And so there's a strategy involved with it. And so there's a gap in there that's not being filled, which I think, uh, Cody Dimak covered a lot of it in the, in the courses that he has on my website, ptsportscare.com slash products.

Um, and just search for Cody Dimak in there. Um, he has a lower and an upper one and it bridges this gap quite a bit. And what I've told a lot of these patients is that is I want them to get strong. They need to build some nice mobility and they need to keep some muscle about them as they age. And it's going to help them age well, feel well, um, be well, and it doesn't really matter where they do it, but the fastest way to lose your gains is to have an injury again. And so if they want me to program for them, I will. If they want me to cue them specific to their problem, I will. Um, at some point there's a handoff, the handoff is they do it themselves or they go with a strength coach or a trainer that who knows the programming, um, and is going to keep on that same goal with them.

And so, um, at some point we're going to phase out, like we're not going to be, I'm not going to be, um, as useful to them as I once was. Um, but most people don't need anything fancy. Push, pull, carry, squat, hinge, Dan John is, um, you heard me interview Dan John and you just, you just go with that. And most people don't need to go extreme and they don't need a bunch of programming changes. They just need about 12 a year. That's at least my theory with it. Um, and if they want to do with me, that's my wellness care. I'm down with that. I like working with a lot of, um, with these patients when they get better.

Um, and when they have successes, like the most mind numbing thing for me is when I'm not helping them succeed and I'm troubleshooting their case and I'm thinking about it. Um, I don't want to think about it. I want to, I want to be happy for these people and I want to work with them, uh, into making it so things don't come back. And so that is the wellness program that I typically provide for people. So those are the two cases of low back, uh, SI hip area that, um, I'm going to cover today. And, uh, remember tell your, if you've not had this problem yourself, you might not quite understand the freak out moments that people have and thinking that maybe it is my tight hip flexor.

Maybe it is my TV and maybe it's my tight hamstring. And by the way, um, there was not a tear probably if there wasn't a bruise. Okay. I'm gonna say it again. There was not a tear if there wasn't a bruise. How do you know there was, how do you know there was tissue disruption? If it wasn't found on an MRI and there wasn't a bruise, like there's no evidence of it. So, um, I cover this all in that workshop, um, on five and six, we cover the, the, uh, soft tissue, uh, injury grading system that, and ways to talk to patients about it because they believe that a lot of them will believe that they had a tear and that their tissue is broken.

And it's not, um, there was no bruise. There was no terror. There was no MRI positive finding. No one's it's a unicorn. No one sees it. Um, there's a, the lake that I go to has a sign up. They say, it says that if Sasquatch and, and the aliens can leave no trace camping, so can you. So if there's no trace of it, it probably wasn't there. So let's just, um, do the very best we can and suggest our patients, um, just settle all the mud and then we can go from there. So, uh, again, if you guys have liked this podcast, please share it with your, uh, friends and every week, at least in the, at the end of the year, I think in December, we're going to go back to every week or so, but until then, we're going to go every other week and just subscribe, hit the subscribe button and hit the share little box with a little arrow that goes up into space or wherever it goes.

Um, share it with a friend right now. Um, this information will not get around unless you share it. I mean that wholeheartedly. So if you want to give me the best compliment you ever can, please share it. All right. And if you want to learn the ways that I'm talking about, and if you want to up your game again, I'm not going to pretend to know everything, but I think I've organized things very well. Um, go, go in and get that, go get the workshop. Okay. I don't make any money on this podcast at all. And so the only way I do ever make any money is and continue the route of, um, improving our profession by helping us piggyback on each other's knowledge is to, uh, is in stuff like the workshop and suggesting, uh, great areas to learn from like Guido Van Ryssegem again and, uh, Michael Shacklock and Stuart McGill and the McKenzie methods.

And, and, uh, I'm sure there's much more Dan John. I'm sure there's much more. Um, so I apologize if I apologize if I miss them. Um, and so, or the Liebansons as well. So sorry, everyone, I'm missing them, but, um, please go through and learn from, from all the people who have some, a lot of knowledge to share. And then you just have to put it all together at one in the same spot. So thanks for being part of the movement. I'll see you guys soon.